INDIVIDUAL LIFE INSURANCE

DEATH CLAIM PROCEDURE

Claim Intimation
To register the claim, claimant needs to intimate us within 90 calendar days from the date of the event. To send an intimation,
please send an email to life. claims@sukoon.com with the below details. Claim reference number will be sent within 3
working days of receiving the intimation email.

1. Policy number
2. Date of Death
3. Place of Death
4. Cause of Death

Claim Processing
For processing the claim, please send the below documents to life.claims@sukoon.com. You can expect to receive the
applicable claim settlement and/or our response within 14 working days of submitting the complete set of documents, as
required by us. For any queries or follow up on your settlement, please write to us at life.claims@sukoon.com.

1. Duly filled Beneficiary claim form.

2. Duly filled Physician statement form filled by the Physician who last attended the deceased life assured.
3. Death certificate. In case of death outside UAE, the certificate needs to be attested by UAE consulate or embassy in the
country where death occurred.
4. In case cause of death is not mentioned on the death certificate, medical report from Physician who last attended the
deceased will be mandatorily required.
5. All medical reports showing history of illness which caused death.
6. Copy of passport with visa page. If death occurs outside UAE, kindly provide the copy of Passport page with stamp
mentioning the date of last exit from UAE.
7. Police report in case of accidental death.

Oman Insurance Company P.S.C. (“Sukoon”) reserves its right to ask for additional documents as may be required and
relevant for claim assessment.

Claim Settlement
If the claim is approved, discharge receipt will be sent to the client for confirmation of the claim amount payable within 7
working days of submitting the claim forms and the documents.
The client needs to sign and stamp the discharge receipt. Once this is received, the amount will be transferred to the bank
account within 14 working days.

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INDIVIDUAL LIFE INSURANCE
DEATH CLAIM FORM

All fields are mandatory. Please complete this form using black or blue ink. Write in BLOCK LETTERS and tick the relevant
items. If the form is incomplete, it might cause a delay. Kindly ensure that you submit a fully filled form together with the
signed annexes, if applicable. Please retain a copy of this claim form and other correspondences with us for your future
reference.

1. Policyholder Details

1. Policy Number

2. In case of additional policies, please mention the numbers below

3. Deceased Life Assured Name

4. Date of Birth Gender Male Female

5. Maiden Name (for married female)

6. Address Building:

Street:

PO Box:

City: Country:

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1. Policyholder Details (continued)

7. Policy Details – Please list all policies that the deceased was holding for life and medical insurance from other companies

Policy Type Sum Insured (AED) Policy Number

2. Treatment and Doctor Details (if applicable)

1. When did the deceased first visit the doctor for the condition that caused death

2. Treating Doctor Name

3. Hospital/Clinic Address Building:

Street:

PO Box:

City: Country:

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2. Treatment and Doctor Details (if applicable) - continued

4. Details of treating doctors in past 5 years

Name Location

5. Please list all hospitals where the deceased was treated or admitted for the condition that caused death

Hospital Name Location

3. Beneficiary Bank Details

1. Account Name

2. Account Number

3. Bank Name

4. IBAN (23 digits)

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4. Beneficiary or Legal Representative Declaration

I hereby authorize Oman Insurance Company P.S.C. (hereinafter referred to as “Sukoon”) to wire transfer claim payouts (if
any) related to this claim form to the above bank details as filled in by me. I understand that Sukoon reserves its right to use
any alternate payout option if required. If ever Sukoon credits more amount than the correct benefit amount due to
duplicate or erroneous funds transfer, I authorize Sukoon to revise the transaction and withdraw the overpayment. I will not
hold Sukoon responsible in any case of non-credit to the above bank account or if the transaction is delayed or not effected
at all for reasons of incomplete/incorrect details filed in by me.

I by signing this form hereby confirm that I am duly legally authorized to fill and claim the policy benefit under the above
mentioned policy. I hereby declare that above statements are true in each and every respect. I hereby authorize and provide
my unconditional consent to any physician, hospital, insurer, medical information bureau or other organization or person
having any records, data or information concerning health history of the deceased life insured to furnish such records, data
or information as may be requested by Sukoon or their duly authorized representative to be provided to Sukoon and for
Sukoon to further release such received and/or policy and claim related information to any other entity as may be required
or requested. I understand that in executing this authorization, I waive the right for such information to be privileged or
confidential. I hereby also agree to indemnify and hold harmless Sukoon against all costs, expenses and liabilities
which may arise as a result of this claim/claim form including any of the details filled in by me in this claim form.

A photocopy of this authorization shall be considered as effective and valid as the original.

Name Date

Signature Relation with Insured

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PHYSICIAN STATEMENT - INDIVIDUAL LIFE INSURANCE
PROOF OF DEATH

1. Physician Statement

1. Date of Death Time of Death

2. Cause of Death Illness Accident Natural Causes Homicide

3. In case of accident, suicide or homicide, please give details of the event

4. Were there any contributory causes of death? Yes No

If yes, please provide details

5. Was there an autopsy? Yes No

If yes, please specify who did the autopsy

and the results of the procedure

6. When did the symptoms first become apparent?

7. Source of history obtained

8. Did the deceased have any chronic condition or deformity? Yes No

If yes, please provide details

9. Was the deceased ever admitted to any institution, sanitarium? Yes No

If yes, please provide details

10. Did you treat the deceased for any illness other than cause of death in past 5 years? Yes No

If yes, please provide details

11. Are you aware of any other physician who treated the deceased for the condition? Yes No

If yes, please provide details

12. Remarks and supplementary data, if any

Name Date

Signature Stamp